Buckle up. I work for the largest health insurance company in the world. While you may not believe this...the insurance company is always on your side. They may deny services but there is always a reason. Medical necessity (and many of these are over turned on a record review), coding issues, true fraud, etc. The ways a provider can be paid is mind boggling. POC (percent of charge), per diem, case rates, carve outs, outpatient fee schedules, DRGs, stop loss clauses, etc. etc. There is massive amounts of abuse in the provider space. Case in point: me. I went to the ER in August for a severe GI bleed. A Ct scan, a colonoscopy and 33 hours of observation left me with patient responsibility of nearly $5,000. My wife and I are blessed with good health so much of this is deductible. I expected a bill. Unfortunately for the provider I'm a senior auditor. They are paid at a percent of charge and billed nearly $5,000 for hydration therapy...for those not in the field those are IV bags. Over the 33 hours they hung 5. I was charged $5K for about $20 of salt water. On the detail bill I requested there is an upadjust line item which reads "Contractual allowence adjustment" of $5,273.58. No one at the provider can tell me what this is? I just attended a town hall meeting for my employer. I forget which indepedent watch dog group just dropped a report but its estimated there is $1 trillion dollars of waste and abuse in the medical industry. And to be fair...this abuse goes both ways. I'm working a project now looking at members who excessively use preventive visits. No, we are not talking people seeing a doctor a few times a year. We are talking those who have 20 or more preventative visits annually. I feel sorry for people who have catastrophic medical claims, see huge bills land at their feet, and have no way of understanding them.